Senate panel: Revised Medicaid plan creates more problems for CHC

The Senate Committee on Health and Welfare will bring together Medicaid officials and patients to a question-and-answer session, citing “frustration” with the lack of information about the revised Medicaid state plan that now requires, among other things, Medicaid patients to seek certification first from the Commonwealth Healthcare Corp. that certain services are not available at CHC before being allowed to go to private clinics and pharmacies.

Some optional services are also now not covered by Medicaid or are being capped by Medicaid.

Sen. Ralph Torres (R-Saipan), chairman of the Senate Committee on Health and Welfare, said yesterday that one of his major concerns about the revised state plan is “not being able to give CHC ample time to stabilize its own workforce” before forcing the corporation to absorb all Medicaid patients except when CHC certifies it cannot provide the services.”

“We’re not helping CHC at all but creating more problems for them and most especially to the patients affected by the revised plan,” Torres said.

He said CHC has been losing physicians and nurses yet Medicaid revised its state plan to require all Medicaid patients to go to CHC first, effective July 1.

“There will be influx in the number of patients that CHC will have to provide services to. I don’t think CHC has the capacity and capability to handle all, unless it certifies that certain services cannot be provided at CHC and therefore allows Medicaid patients to go to private clinics,” he added.

Torres believes that not much information about the plan is coming out from Medicaid or CHC.

“We are also getting information from them little by little. We want to know, for example, the kinds of services that the CHC [chief executive officer] could certify as not available at CHC so he can refer the students to private providers like clinics. So far we only know of St. Jude Renal Care that CHC can refer Medicaid patients too because CHC cannot accommodate the number of dialysis services needed by patients,” he said.

Torres, at the same time, said the Health and Welfare and the Fiscal Affairs committees are looking at increasing Medicaid funding under the fiscal year 2013 budget.

“One of the proposals is to use money from vacant fulltime employee positions and give those funding to Medicaid. Increasing Medicaid funding is one of the committee’s priorities,” he said.

Sen. Jovita Taimanao (Ind-Rota), chairperson of the Fiscal Affairs Committee, also said her panel is looking at increasing funding for critical needs and agencies such as for Medicaid and medical referral.

Both committees will meet on the issue this week.

Senate President Paul Manglona (Ind-Rota), for his part, said Medicaid still owes private providers in the CNMI, Guam, Hawaii, and other U.S. states some $13 million in unpaid reimbursements.

In the CNMI alone, there are 24 vendors owed money by Medicaid.

Manglona said these include PHI Pharmacy ($2.1 million), Seventh-Day Adventist Clinic ($936,000), Pacific Medical Center ($933,000), Hardt Eye Clinic ($768,000), Marianas Medical Center ($574,000), Smile Marianas ($475,000), St. Jude Renal Care ($426,000), Marianas Eye Institute ($380,000), Saipan Health Clinic ($254,000), Marianas Visiting Nurses ($232,000), Toothworks ($207,000), Marianas Health Services Home Care ($200,000), Diamond Home Healthcare ($116,000), Healthcare Specialists ($111,000), Brabu Pharmacy ($111,000).

The other CNMI providers owed Medicaid money, according to Manglona, are Kaise Home Health Agency ($95,000), Modern Solution ($59,000), August Healthcare Group ($38,000), Pacific Laboratories ($28,000), Dental Care ($25,000), PT Rehab ($22,000), Marianas Medical Supply ($20,000), Hippocrates ($4,000), and Hippocrates Sleep ($4,000).

Guam-based providers are owed $758,000, while those in Hawaii and the U.S. are owed $.3 million, Manglona added.

In the revised Medicaid state plan, home health services are covered but the providers need to be Medicare-certified home health agencies and must be medically necessary.

It says the fact that a provider has prescribed, recommended, or approved the services or items does not, in itself, make such services or items medically necessary or a covered service. It adds that the Medicaid agency will make determination upon review of the claim and/or medical record.

Other restrictions include those on the provision of wheelchairs. Only one wheelchair is allowed every five years. Only standard, manually operated wheelchairs are covered. Motorized chairs including its replacement parts are not covered.

On dental services, orthodontics, prosthetics and root canal are not covered services. Coverage of oral surgery is limited to emergencies. Coverage is limited to age 19 and under, unless it is necessary for relief and pain infection only.